Full name & pronouns * Within the last year have you been under a dermatologist care? Yes No If yes please specify Have you had any health problems in the past or present? Yes No If yes, Please specify Please select any of the below skin health concerns Breakout Oiliness Congestion Premature Aging General Healthy skin Uneven Skin tone List any medications that you consume regularly Do you ever experience any tightness, Flakiness or obvious dryness on the skin? Yes No What are your specific concerns/challenges with your skin? Do you smoke? Yes No Do you exercise regularly? Yes No Do you wear contact lenses? Yes No Do you have any body piercings? Yes No Do you have any metal implants or pacemaker? * Yes No Please list any allergies * Do you sunbathe or use tanning beds? Yes No Do you drink more than 4 caffeinated beverages daily? Yes No Have you had any botox or filler in the last 14 days? * Yes No Have you had surgery in the last six months? * Yes No Please list the current skincare brands/products you're currently using What SPF sunscreen do you use on the face? Do you burn easily in moderate sunlight? Yes No Have you ever had chemical peels, Microdermabrasion or any other skin resurfacing treatments? Yes No Do you use Retin-A, Adapalene or any prescription skin products? * Yes No Are you currently using any products containing any of the following: Glycolic acid/ Lactic acid/ Exfoliating scrubs/ Salicylic acid and or Vitamin A derivatives (i.e Retinol) * Yes No Have you waxed any areas of the face in the last 72 hours? * Yes No Do you have a tendency to redness? Yes No Do you ever experience burning, itching or stinging sensations on the skin? Yes No If yes, please explain Are you taking oral contraception? * Yes No Are you pregnant or trying to become pregnant? * Yes No Are you currently nursing? * Yes No Are you currently having or due for your menstrual? Yes No Thanks so much! I’m excited to have you come in! Consult Consult Consult
